Objective: The aim of the study was to find the effect of ankle foot orthosis (AFO) on energy expenditure (EE) during walking in children with spastic diplegia (SD) due to cerebral palsy (CP). Materials and methods: Twenty-six subjects with SD CP who could ambulate with and without the help of orthosis were selected after screening with inclusion criteria. The EE of these patients during ambulation with and without orthoses was measured using the K4b² machine. Statistical analysis was performed with the help of Epi Info^TM 3.5.3. t-test, chi-square test, and correlation tests were used to study the parameters of oxygen cost, oxygen pulse, heart rate, and EE. Results: The use of AFO resulted in decreased EE in 73% of patients in the first day itself. In the sequential assessment, these patients showed further decrease in EE with AFO use. The patients who initially showed an increase of EE also showed a decrease in the rise in EE during walking in their subsequent analysis. Oxygen cost also showed a positive correlation with EE. Heart rate was not much related to use of AFO; rather, it showed an increase in the assessment done second in the same day (among walking with and without the AFO). There was no linear relation or correlation between O₂ pulse and other parameters of the study. Conclusion: The AFOs are an important intervention in the treatment of SDs. It can help decrease the EE and improve the speed of walking in most patients when prescribed along with other needful therapies like exercises, antispastic medications, etc. O₂ cost showed positive correlation with EE analysis. In patients with increased EE with AFO use, the mean difference between EE with and without AFO decreases, suggesting long-term benefits that AFO could offer. A study of longer duration with more patients should be conducted to view the full benefits of AFO in children with SD CP.

In the management of benign joint hypermobility syndrome (BJHS), there is no clear-cut idea regarding the types of exercises which will be appropriate to incorporate in the management protocol of this unique condition. According to some the extensor muscles group should be strengthened and some other opined to strengthen both the extensor and flexor groups of muscles. We presume that strengthening of both the extensor and flexor will be more beneficial because it will provide balance between two opposing groups of muscle and hence, give more stability to the joint and the isometric strengthening exercise would be the exercise of choice. In our study for therapeutic exercise, the 61 patients were grouped into two randomly. Group I (30 patients) were instructed to perform only isometric strengthening exercise for only extensor group of muscles. Group II (31 patients) were advised to do isometric strengthening exercise for both the extensors and flexors group of muscles. After 6 weeks of therapy we found group II is showing a superior result.

Introduction: Moyamoya disease is an uncommon cerebrovascular disease characterized by progressive steno-occlusive changes in terminal internal carotid arteries (ICAs) and their main branches, associated with development of moyamoya vessels.¹ We present the largest case series of childhood moyamoya disease from India. Materials and methods: Thirty patients of childhood Moyamoya disease, whose diagnosis was confirmed by magnetic resonance imaging (MRI), MR angiography (MRA), and digital subtraction angiography (DSA), were studied for various spectrum of clinical and radiological manifestations. Results: Of the 30 patients evaluated (mean age: 6.71 years; F:M ratio 1.15:1), majority (96.66%) presented with ischemic symptoms, whereas only one (3.33%) had hemorrhagic stroke. Ischemic stroke with hemiparesis was the most common presenting feature (66.66%); rarer manifestations of moyamoya disease like headache, seizures, cognitive decline, visual loss, and bihemispherical transient ischemic attacks (TIAs) were also seen as presenting features. Radiologically, other than ischemic and hemorrhagic stroke, normal parenchyma with abnormal flow voids was the uncommon pattern seen on MRI brain, seen in 23.33%; 1 patient had isolated corpus callosal infarct. On angiography, 21 (70%) had bilateral ICA disease, 5 (16.66%) had unilateral ICA disease, and 4 (13.33%) had bilateral ICA with associated posterior circulation involvement. Conclusion: Other than seizures and strokes, headache, cognitive decline, bihemispherical TIAs and isolated corpus callosal involvement were the unusual presentations found in this study. Radiologically, unilateral affection and posterior circulation involvement were also found. It is important to be familiar with the usual and unusual clinical manifestations and MRI/MRA findings in moyamoya disease to make an early diagnosis leading to a good prognosis.

The os trigonum is a tiny bone found on the posterolateral aspect of the talus. It has a separate ossification center which does not unite with the talus itself. It is difficult to make the diagnosis, as clinical features and physical examination findings mimic those that occur with conditions related to flexor hallucis longus, an accessory soleus muscle, peroneal tendons, tibialis posterior, or arthritis of the posterior subtalar or tibiotalar joints. Misdiagnosis may lead to inadequate management which includes early weight bearing and unrelieved symptoms. This syndrome is found mostly in ballet dancers, runners, and soccer players.